Implementation of Palliative Care Report Palliative care ...
Managing Opioid Misuse in Palliative Care Settings: How Prepared Do Hospice and Palliative Medicine...
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pain (41% vs 27%, p ¼ 0.032), fatigue (47% vs 34%, p ¼ 0.042), and depression (41% vs 27%, p ¼ 0.046). Patients with no evidence of disease had less fatigue (27% vs 52%, p ¼ 0.002), anxiety (36% vs 60%, p ¼ 0.003), and depression (24% vs 39%, p ¼ 0.016). Patients with history of anxiety, depression, or chronic pain had more pain (56% vs 30%, p ¼ 0.003), fatigue (60% vs 39%, p ¼ 0.016), anxiety (68% vs 47%, p ¼ 0.021), and depression (48% vs 30%, p ¼ 0.046). No significant differences in symptom burden by can- cer type or stage. Conclusion. Gynecologic oncology outpatients have a high symptom burden, especially fatigue and anxiety, regardless of cancer type and stage. Symptom burden is higher among younger pa- tients and patients with history of depression, anxiety, or chronic pain. Implications for research, policy, or practice. Consideration should be given to targeting these patients for outpatient palliative care services. Domain Physical Aspects of Care Lessons from Rural Volunteer Hospices: Thinking Outside the Medicare Box (411-C) Solomon Liao, MD FAAHPM, University of Cal- ifornia Irvine, Orange, CA. Jared Garrison-Jakel, MD MPH, Santa Rosa Family Medicine Resi- dency, Santa Rosa, CA. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Discuss creative approaches to providing hos- pice and palliative care to under-served populations. 2. Describe the volunteer hospice model. 3. Discuss the current state of rural hospices in California. Background. Once the only form of hospice in the United States, volunteer hospices have, since the Medicare hospice benefits, become a small minority. Little is known about their current model of care. Research objectives. Describe the current struc- ture and practice of volunteer hospices in California. Methods. Qualitative, semi-structured, key- informant interviews of four volunteer hospice programs in a rural county in California Results. Volunteer hospices have developed in- novative ways to provide comprehensive end-of- life care without Medicare hospice benefits, in- volving community partnerships, efficient resource utilization, and funding support from their community. Since volunteer hospices in the study were prohibited from providing skilled nursing, they focused on care-coordination; edu- cation and training of caregivers, volunteers, and the community; and provision of spiritual and bereavement care. Their utilization of exist- ing nursing and pharmacy resources and com- munity support allowed them to successfully provide care to rural, under-served, and low-re- source areas. However, volunteer hospices felt alienated from the larger hospice community. Conclusion. The volunteer hospice model, with- out a reliance on Medicare hospice benefits, of- fers creative approaches to providing hospice and palliative care to under-served populations, such as the under-insured and those in nursing homes and rural areas. More engagement of volunteer hospices is needed in research and in national organizations. Implications for research, policy, or practice. Medicare-certified hospices can use the same approaches currently used by volunteer hospices to provide care to under-served populations not covered by or inadequately covered by their insurances. Domain Structure and Processes of Care Managing Opioid Misuse in Palliative Care Settings: How Prepared Do Hospice and Palliative Medicine Fellows Feel? (412-A) Julie Childers, MD, University of Pittsburgh Medical Center, Pittsburgh, PA. Robert Arnold, MD, University of Pittsburgh, Pittsburgh, PA. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the percentage of hospice and palli- ative medicine fellows who had encountered a patient at risk for opioid misuse within a 2- week period. 2. Describe the domains in which hospice and pal- liative medicine expressed particular challenges in treating patients at risk for opioid misuse. 3. Rate education in substance use disorders and opioid misuse as an important objective for future palliative medicine specialists. Background. As palliative care becomes inte- grated earlier in patients’ diseases, palliative Vol. 41 No. 1 January 2011 227 Schedule with Abstracts
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Transcript of Managing Opioid Misuse in Palliative Care Settings: How Prepared Do Hospice and Palliative Medicine...
Vol. 41 No. 1 January 2011 227Schedule with Abstracts
pain (41% vs 27%, p ¼ 0.032), fatigue (47% vs34%, p ¼ 0.042), and depression (41% vs 27%, p¼ 0.046). Patients with no evidence of diseasehad less fatigue (27% vs 52%, p ¼ 0.002), anxiety(36% vs 60%, p¼ 0.003), and depression (24% vs39%, p ¼ 0.016). Patients with history of anxiety,depression, or chronic pain had more pain(56% vs 30%, p ¼ 0.003), fatigue (60% vs 39%,p ¼ 0.016), anxiety (68% vs 47%, p ¼ 0.021),and depression (48% vs 30%, p ¼ 0.046). Nosignificant differences in symptomburdenby can-cer type or stage.Conclusion. Gynecologic oncology outpatientshave a high symptom burden, especially fatigueand anxiety, regardless of cancer type and stage.Symptom burden is higher among younger pa-tients and patients with history of depression,anxiety, or chronic pain.Implications for research, policy, or practice.Consideration should be given to targeting thesepatients for outpatient palliative care services.
DomainPhysical Aspects of Care
Lessons from Rural Volunteer Hospices:Thinking Outside the Medicare Box (411-C)Solomon Liao, MD FAAHPM, University of Cal-ifornia Irvine, Orange, CA. Jared Garrison-Jakel,MD MPH, Santa Rosa Family Medicine Resi-dency, Santa Rosa, CA.(All speakers for this session have disclosed norelevant financial relationships.)
Objectives1. Discuss creative approaches to providing hos-
pice and palliative care to under-servedpopulations.
2. Describe the volunteer hospice model.3. Discuss the current state of rural hospices in
California.Background. Once the only form of hospice inthe United States, volunteer hospices have, sincethe Medicare hospice benefits, become a smallminority. Little is known about their currentmodel of care.Research objectives. Describe the current struc-ture and practice of volunteer hospices inCalifornia.Methods. Qualitative, semi-structured, key-informant interviews of four volunteer hospiceprograms in a rural county in CaliforniaResults. Volunteer hospices have developed in-novative ways to provide comprehensive end-of-
life care without Medicare hospice benefits, in-volving community partnerships, efficientresource utilization, and funding support fromtheir community. Since volunteer hospices inthe study were prohibited from providing skillednursing, they focused on care-coordination; edu-cation and training of caregivers, volunteers,and the community; and provision of spiritualand bereavement care. Their utilization of exist-ing nursing and pharmacy resources and com-munity support allowed them to successfullyprovide care to rural, under-served, and low-re-source areas. However, volunteer hospices feltalienated from the larger hospice community.Conclusion. The volunteer hospice model, with-out a reliance on Medicare hospice benefits, of-fers creative approaches to providing hospiceand palliative care to under-served populations,such as the under-insured and those in nursinghomes and rural areas. More engagement ofvolunteer hospices is needed in research andin national organizations.Implications for research, policy, or practice.Medicare-certified hospices can use the sameapproaches currently used by volunteer hospicesto provide care to under-served populations notcovered by or inadequately covered by theirinsurances.
DomainStructure and Processes of Care
Managing Opioid Misuse in Palliative CareSettings: How Prepared Do Hospice andPalliative Medicine Fellows Feel? (412-A)Julie Childers, MD, University of PittsburghMedical Center, Pittsburgh, PA. Robert Arnold,MD, University of Pittsburgh, Pittsburgh, PA.(All speakers for this session have disclosed norelevant financial relationships.)
Objectives1. Describe the percentage of hospice and palli-
ative medicine fellows who had encountereda patient at risk for opioid misuse within a 2-week period.
2. Describe the domains in which hospice and pal-liativemedicineexpressedparticular challengesin treating patients at risk for opioid misuse.
3. Rate education in substance use disordersand opioid misuse as an important objectivefor future palliative medicine specialists.
Background. As palliative care becomes inte-grated earlier in patients’ diseases, palliative
228 Vol. 41 No. 1 January 2011Schedule with Abstracts
care providers may treat more patients who mis-use opioids. It is unknown how well-preparedhospice and palliative medicine (HPM) fellowsare to treat pain in these patients.Research objectives. Assess how frequently HPMfellows treat patients with substance use disorders(SUDs) and prescription opioid misuse and howprepared they feel to treat these patients.Methods. With input from experts in addictionand palliative medicine, we developed a surveyasking about fellows’ perceived competence indomains related to treating patients at risk foropioid misuse. Responses were rated using a 7-point Likert scale where 1 ¼ strongly agree and 7¼ strongly disagree. We considered a 1 and 2 to in-dicate agreement, 3e5 as neutral, and 6 or 7 indi-cated disagreement. We distributed the onlinesurvey by e-mail to all HPM fellows.Results. Fifty-seven of the 102 fellows contacted(55.6%) completed the survey. In the previoustwoweeks, 77.2%of respondents had treated a pa-tient with a SUD and 43.9% had treated a patientwho was misusing opioids. Half (47.2%) of re-spondents agreed that they have a working knowl-edge of addiction, and 41.4% agreed they feelprepared to treat pain and symptoms in patientswith SUDs. Specifically, 36.8% agreed that theycan identify requests for pain medication thatare due to addiction; 24.6% feel comfortablemanaging patients with lost or stolen pain medi-cations; 33.3% agreed that they could diagnosea SUD in apatient for whom theywereprescribingopioids. Twenty-one percent were satisfied withhow they treat symptoms in patients with SUDs.Conclusion. HPM fellows regularly see patientsat risk for opioid misuse and express limitedcompetency in treating pain in these patients.Implications for research, policy, or practice.There is a need for more education of HPM fel-lows in this area.
DomainStructure and Processes of Care
Screening for Substance Abuse and Diversionin Virginia Hospices (412-B)Leslie Blackhall, MD MTS, University of Virginia,Ivy, VA. Elizabeth Alfson, MD, Harvard Long-wood Psychiatry Residency Training Program,Boston, MA. Joshua Barclay, MS MD, Universityof Virginia, Charlottesville, VA.(All speakers for this session have disclosed norelevant financial relationships.)
Objectives1. Describe the current national trends regard-
ing the use of opioids and increasing levelsof drug abuse, diversion, and mortality, andpotential impact of these trends for hospiceproviders.
2. Describe current policies of Virginia hospicesregarding drug abuse, diversion, and trainingof staff.
3. Discuss the need for appropriate policies andprocedures regarding drug abuse and diver-sion in the hospice population, and the obsta-cles to the development and implementationof those policies.
Background. Although inadequate treatment ofpain continues to be a major problem for pa-tients at the end of life, evidence exists that in-creases in the medical use of opioids havebeen accompanied by increasing levels of opioidabuse and diversion in the community. Hospicepatients are commonly prescribed opioids totreat pain and may have large amounts of con-trolled substances in their homes. Balancingthe mission of pain relief with concerns aboutabuse and diversion is a difficult issue for hos-pice agencies.Research objectives. Determine policies andpractices in Virginia hospices regarding sub-stance abuse anddiversion in patients. Determinepolicies and practices in Virginia hospices regard-ing substance abuse and diversion in family mem-bers of patients.Methods. Survey of all Virginia hospices aboutpolicies, perceptions, and training regardingsubstance abuse and diversion.Results. Twenty-three of 63 hospice agencies re-sponded (36.5%). Less than half (43.8%) re-quired mandatory substance abuse training.Only 43.5% had policies regarding screening forsubstance abuse inpatients; 30.4%had apolicy re-garding screening for substance abuse in familymembers. Policies regarding screening for diver-sion in patients (21.7%), and families (17.4%)were rare. Policies regarding opioid use in pa-tients with a history of substance abuse or diver-sion were uncommon (33.3%, 30.4%,respectively); 30.4% had policies regarding useof opioids in patients whose family membershad a history of diversion or abuse. Thirty-eightpercent of responding hospices agreed that sub-stance abuse and diversion was a problem fortheir agency, and these agencies were more likelyto have written policies or mandatory training.
